Guardian Long-Term Disability Denial

Guardian Long-Term Disability Denials

Guardian Life Insurance Company/Berkshire is a major writer of disability insurance in the United States. It writes both individual disability income policies and group policies governed by the federal law known as ERISA.

Guardian/Berkshire holds itself out as a premium insurer, offering expensive insurance products to doctors, lawyers, salaried executives and other high income professionals. Guardian, like most disability insurers, offers a wide variety of policy features. The higher the level of protection, the higher the premiums. Unfortunately, even with the most feature-rich and expensive policies, they do not always deliver in a way that meets consumer’s expectations.

At Robinson & Warncke, we understand how important your disability benefits are to you and your family. We will fight tirelessly to help ensure that the insurance company into whose policy you’ve paid into makes good on their promise to pay out when the time comes. If you have received a Guardian long-term disability denial, contact us today.

Is Guardian Denying More Disability Claims Than Usual?

We have experienced a noticeable uptick in Guardian/Berkshire disability claim denials and benefit terminations beginning in late 2019 and continuing into 2020. Although Guardian had traditionally been one of the better companies for giving its insureds the benefit of the doubt, that approach appears to be changing.  We have spoken to a number of clients who had received Guardian disability benefits for years but whose benefits were suddenly cut off despite no meaningful improvement in their health. This phenomenon seems to be occurring most frequently with high benefit claims for high-wage-earning professionals, including doctors, dentists and lawyers. Oftentimes, the adverse claim decisions are based on little more than a medical records review by a remote consulting physician who has never even met the patient.  There is a cottage industry of doctors who routinely review records for disability insurers, often second guessing treating physicians with years of experience treating the patient. 

Even though Guardian’s reputation has historically been excellent, there are also a growing number of legitimate, new disability insurance claims filed each year that Guardian wrongfully denies. Guardian disability insurance claim denials and benefit terminations can be appealed and overturned with the help of an experienced long-term disability insurance attorney.

The attorneys at Robinson & Warncke have decades of experience litigating claims against Guardian and other insurance companies who wrongfully deny coverage to their policyholders and beneficiaries. If you’ve had your benefits denied by Guardian, call us today and set up and appointment. We can help.

How Do Guardian’s Long-Term Disability Policies Work?

Guardian, like any insurance company, makes money based on its underwriting guidelines. In other words, it calculates risk based on your job, health and lifestyle and then makes a determination as to whether or not they write a policy for you, and on what terms. This makes it very difficult for some individuals to get policies through Guardian and very easy for others.

Guardian Life and its subsidiary Berkshire Life Insurance Company of America both offer various kinds of long-term disability policies. The policies are meant to pay out in the event that you are sick or injured and can no longer perform the functions of your “occupation,” a term of art that has different meanings in different contexts.

Generally, Guardian markets its policies toward “professional” workers. These include doctors, lawyers, accountants, corporate employees, and others who engage in low-risk labor. These policies act as a kind of income insurance if you are no longer able to meet the demands of your work. They subsidize your income so that it can get back to some percentage of what you earned before.  However, the devil is in the details of the policy language.

Understanding the Different Categories

These policies fall into different categories, as listed below:

Employer-sponsored group disability insurance

These are group policies that are purchased by your employer. They usually have an elimination period during which new employees would not qualify under the terms of the policy. However, those who were denied individual policies may find it easier to obtain coverage under a group policy offered through work. One drawback is that these policies only pay out 50% to 60% of your base income, with even that amount reduced by a number of Other Income Benefits. These plans are subject to a federal law called ERISA. ERISA contains a number of features that erode the protections otherwise afforded consumers under state insurance laws. For more about ERISA, click here.

Business owner’s disability insurance

If you run your own business or are a sole proprietor, you can opt into a business insurance plan. This plan covers your business if you are no longer able to run it. It covers such things as key-man insurance policies, business loan payments, and payments. In other words, it keeps your business going even if you’re not able to run it.

Individual long-term disability insurance

This insurance policy is subject to the strictest underwriting guidelines if you go through Guardian. These individual policies are generally considered better than group policies covered by ERISA.  They pay a specified monthly benefit, which, depending on specific policy terms, may be payable if you cannot work in your insured “occupation” even if you can, and actually do, work in some other occupation.

Partial disability insurance

For those who have lost the ability to do some (but not all) of their job, Guardian offers a partial disability feature. Partial disability generally exists when you have a disability causes at least a 20% loss in income compared to your pre-disability earnings. Partial disability claims can present some of the highest complexity challenges in all of disability law. These include:

• Determining whether the insured is in fact partially versus totally disabled. A classic example would be a surgeon who cannot perform surgery, and is reduced to performing office consultations at a deeply reduced income. Depending on several factors including policy language and the doctor’s earning levels pre- and post-disability, Guardian may have to pay either the full total disability benefit, or only the partial disability benefit taking into account earnings during disability.  The difference in the value of benefits can be substantial, and the technical nature of this inquiry often requires expert involvement for the insured.
• Determination of the pre-disability earnings and post-disability earnings creates a burdensome documentation requirement for the insured, and often leads to disagreements with the insurer. Again, an expert disability attorney can anticipate the issue and present this proof to Guardian in the most advantageous way for this insured.

Determining whether an insured is still working in the insured “occupation” often leads to disagreements. In one such case, Robinson & Warncke attorneys were able to persuade Guardian to reverse its finding that a doctor insured in her specialty of Emergency Medicine was entitled to Total Disability benefits because her medical condition only allowed her to work in the much less demanding, and much less lucrative, specialty of Urgent Care (i.e. Doc-in-a-Box).  This dispute took more than a year to resolve, and required, among other things, the input of a nationally renowned CPT billing/coding expert.  By carefully documenting every detail, Robinson Warncke attorneys were able to recover more than a million dollars in benefits which Guardian had tried to dispute.

Guardian Does Not Extend Policies to Certain Workers

Unlike most of the insurance companies that offer disability insurance, Guardian has a very high consumer satisfaction rating. This is due to the fact that Guardian will not extend policies to certain workers and due to the fact that their claims service if oftentimes quite good. The workers who are extended policies are considered very low-risk workers and hence fewer claims are filed against their policies. Those who do qualify under their policies find the process of filing claims quite easy. That isn’t always the case, however.

Filing a Claim on a Guardian Disability Insurance Policy

The process of filing a claim on a Guardian policy is identical for both short-term and long-term disability claims. You are expected to provide the following information:

• Statement of disability. Here, you outline what your disability is and how it prevents you from performing certain tasks required by your work.
• Employer’s statement. Your employer will file a statement to verify the details of your claim.
• Doctor’s statement. Your doctor will submit medical reports that provide medical evidence that you’re as disabled as you say you are.
• Earnings documentation, which can include tax returns and other supporting documents.
• In the case of disabled physicians, CPT Code histories from which your duties will be determined.
• In the case of disabled dentists, CDT Code histories from which your duties will be determined.

Once your forms are completely filled out, Guardian/Berkshire should issue a letter of receipt to both you and your employer acknowledging that they received the forms. If you don’t receive this letter, you should follow up with the insurance company.

Dealing With Claim Delays

Delays may occur when the insurance company requests more information. Sometimes, these may be honest requests, simply asking for medical records and other information that Guardian hasn’t received.

In other cases, however, Guardian will bounce you back and forth between your doctor and the claims manager, and it may feel like they can’t ever get on the same page. When this happens, Guardian may be stalling or otherwise giving you the run-around. A Guardian long-term disability denial lawyer can help you identify these tactics and help you move the process along. Robinson & Warncke has had occasion to tell Guardian claims people that their requests had gone too far afield, and were delving into irrelevant or cumulative matters. Sometimes it takes an experienced disability attorney making an implied (or overt) threat of litigation to put a stop to the “investigation” and force a claim decision.

Dealing With Claim Denials

When an insurance company denies a disability claim, they are required to provide you with a reason for the denial in a notice. Make sure to review the notice carefully. The letter will inform you that you have the right to appeal, tell you the process for doing so, and give you a deadline for filing an appeal. If you miss this deadline, you may not be able to collect on your policy. Should You Handle Your Own ERISA Appeal? No, and here’s why. . .

It’s also important to speak to an experienced disability lawyer who knows how insurance companies work, as well as how to level the playing field. Whether it’s working towards a settlement, going through an appeal, or litigating your case in court, we can fight to make sure you protect your rights.

Why Was Your Guardian Disability Insurance Claim Denied?

There are a number of reasons why Guardian might  deny a disability claim. In our experience, the common reasons include:

• Guardian’s own doctor alleges you aren’t disabled. Guardian hires doctors to conduct medical reviews, often through third-party companies that exclusively serve the disability insurance industry. There is reason to be concerned whether these medical review companies that exist solely to serve disability insurance companies are fairly selecting physicians to review claims.  There is also reason to be concerned whether the reviewing doctors have been given complete information and whether their opinions are free from influence. Sometimes frequently-used consulting doctors render decisions on conditions outside of their own specialties and experience.  More often, these doctors “cherry pick” the medical records citing problems in a patient’s records but failing to acknowledge the portions of those records that support the disability claim. Having never even met you, the insurance consultants simply cannot see for themselves how your condition impairs you and causes your symptoms.  
• Guardian-hired private investigator has video of you. Guardian sometimes hires private investigators to perform video surveillance. Surveillance is typically conducted over the course of several days, but the recordings only focus on the times when you are outside your home – not the long periods when you are home resting or even incapacitated by symptoms. Because of this inherent selectivity, the videos can make you appear more capable of activity than you really are. 

• Guardian sends you for functional capacity evaluation or medical examination. Guardian may also send you for a functional capacity exam (FCE) or medical examination with a company, physician or psychologist it routinely uses in this type of claim  The medical examinations can last as little as 20-30 minutes, offering only a limited snapshot of how your condition impacts your abilities.  We have seen examination results cited as a reason to deny a claim when those same results, if they are accurately compared to the patient’s policy definitions and work requirements, actually supported the disability claim. 

• Guardian-hired doctor speaks to your physician. A Guardian-hired doctor may reach out to your attending physician, oftentimes by telephone, unscheduled and unannounced. Several of our client’s treating doctors have told us an insurance company doctor caught them unprepared for the call, without access to the patient record, and then aggressively pushed the treating doctor to agree the patient can return to work. We also know of instance instances where the insurance company doctor has misreported the conversation. Experienced disability attorneys know how to guard against this much-abused process.
• Guardian misuses CPT or CDT Billing code analysis to assert your occupation is less demanding than it actually was.  Many Guardian policies are “own occupation” for the duration of any claim. This is better and more expensive coverage than “any occupation” coverage. Guardian also sells an even higher, and still more expensive, form of coverage that protects doctors’, dentists’, and attorneys’ ability to practice in their “own specialty.”  These policies are supposed to pay out if you can’t work in your chosen specialty, even if you can do other, less demanding work within your profession. Guardian and other disability insurers might request doctors’ CPT billing codes, or dentists CDT billing codes, to suggest that you weren’t really working in your specialty. This seriously dilutes the protection supposedly afforded by the most expensive coverage offered on the market.  And these billing codes are not always interpreted properly or legally.
• Own occupation/Any occupation claims. While most individual policies define “disability” in terms of your inability to perform your regular occupation or specialty, other policies, including group coverage offered to company employees, change the definition of “disability” after a certain period (usually 24 months) of benefits have been paid.   For instance, after 24 months, your policy might only continue to pay you benefits if you are able to show you are no longer able to perform any occupation. Guardian may attempt to have one of its vocational experts identify jobs that are less mentally or physically demanding to argue you could work in those occupations.  We have the ability to obtain independent vocational experts to review and frequently challenge those conclusions.

Contact a Long-Term Disability Denial Attorney Today

If you’ve had a benefit claim  denied or terminated by Guardian, you will benefit from the resources, experience and success our attorneys have in handling Guardian disability claims.  Call Robinson & Warncke today to learn more about how we can help.